Replaced right hepatic artery passing anterior to pancreas: a rare and challenging anatomical variant during pancreaticoduodenectomy

D Raghavendra,Sudeepta Kumar Swain,T G Balachandar,N Sunil,J Nirmal,R Prabhakaran,Himanshu Shekhar

doi:10.1186/s43055-022-00721-3

D Raghavendra, Sudeepta Kumar Swain + Show 5 more

Open Access

https://doi.org/10.1186/s43055-022-00721-3

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Abstract

BackgroundDuring pancreaticoduodenectomy proper dissection of local vessels is required. Normal coeliac and hepatic arterial anatomy can be found in only 50–70% of individuals. Good knowledge about aberrant vascular anatomies is necessary to avoid unnecessary complications.Case presentationAn elderly gentleman presented to us with history of jaundice. Periampullary carcinoma with abnormal right and left hepatic artery morphology was discovered after a contrast enhanced computerized tomography scan.ConclusionDespite the anomalous origin and anterior course of replaced right hepatic artery, Classical pancreatoduodenectomy with preservation of replaced right hepatic artery and regional lymphadenectomy with no major intra and post-operative problems was conducted by superior mesenteric artery first approach. Prior to major hepato-pancreatobiliary surgery, a thorough examination of a contrast enhanced computerized tomography scan is required to understand vascular anatomy, recognize anomalous vessels, and understand their significance. Nevertheless, if the abnormal vessel anatomy like replaced right hepatic artery are identified during surgery, a careful dissection of the anomalous vessel is essential to identify all vascular relationships and avoid irreversible injury.

Highlights

During pancreaticoduodenectomy proper dissection of local vessels is required
Despite the anomalous origin and anterior course of replaced right hepatic artery, Classical pancreatoduodenectomy with preservation of replaced right hepatic artery and regional lymphadenectomy with no major intra and post-operative problems was conducted by superior mesenteric artery first approach
If the abnormal vessel anatomy like replaced right hepatic artery are identified during surgery, a careful dissection of the anomalous vessel is essential to identify all vascular relationships and avoid irreversible injury

Summary

Conclusion

The most common aberration in the hepatic arterial tree is an aberrant right hepatic artery. A careful examination of contrast enhanced CT scan is essential prior to major hepato-pancreatobiliary surgery, to grasp vascular anatomy, locate anomalous vessels, and understand their relevance to avoid unintended adverse effects. Vascular anomaly may determine surgery strategy, as in this case, the SMA first approach. Careful preoperative contrast enhanced CT scan examination and meticulous surgical technique, increases the possibility of preserving an aberrant hepatic artery and avoiding morbidity post operatively

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